The Register Report, Fall 2008 Integrated Training and Practice in Primary Care: Postdoctoral Psychology Fellowship and Medical Residency Training Partnership at Genesys Regional Medical Center in Grand Blanc, Michigan by: Mark E. Vogel, Ph.D., ABPP, Heather Kirkpatrick, Ph.D., ABPP, and Maria Fimiani, Psy.D.  Return to Table of Contents

As medical care moves well into the 21st century, there are increasing calls for enhanced integration of psychology and medical practice. With the focus on healthcare quality improvement we have seen efforts to increase coordinated care, eliminate unnecessary steps or hand offs, increase use of patient-centered teams, and improve access to care (IOM, 2001; Berwick, 2008). At the same time efforts focus on lowering per capita cost of healthcare for a population (Berwick, 2008). Integration of behavioral healthcare in primary care can help achieve these challenging goals. This paper illustrates our experiences in teaching and working in this type of training environment.

INTEGRATED CARE MODELS

The term integrated healthcare (IHC) can be defined by the dimensions considered (staffing, organizational framing, population treated, system of care structure and other variables). Doherty, McDaniel, & Baird (1996) suggest a five step hierarchical model of increasing levels of integration and collaboration between mental health professionals and medical physicians and nurses. Their model describes the strengths and limitations of each level of integration and the settings and types of problems appropriate to each. Strosahl (1996) outlines a three level model for partitioning care according to the needs of the population. Additional models focus on integration for different types of patients (i.e., the chronic high utilizing patient, a specific age of disease category, etc.). For the purposes of this article, we focus on three levels of collaboration: co-location of services, consultative/collaborative, and fully integrated. Co-location is a natural given that a working relationship starts with physical proximity. Our model goes beyond this entry point to develop more consultative/collaborative care in which there is a shared medical record, efforts to coordinate care, and a basic understanding and appreciation for each other’s roles in the care of the patient. Finally, some elements of our program operate in a fully integrated care model where psychology and medicine function as a coordinated team.

PRIMARY CARE

The point of care for our integrated environment is the primary care setting. A major portion of mental health care is rendered in the primary care setting, and always will be (deGruy, 1996). Nearly half of all mental health care is delivered through primary care settings and non-psychiatric physicians prescribe approximately 75% of all psychotropic agents in the U.S. (Gallo, 2000; Williams, 1989). Surveys have shown that for patients diagnosed as either generalized anxiety disorder or clinical depression, it was the primary care/family physician (48%) who first made the diagnosis. (National Mental Health Association, 2001). At the same time, numerous primary care physicians (PCPs) experience frustration that many of the most common physical complaints in primary care often have no diagnosable organic etiology.

On a broader level, primary medical care has placed a new emphasis on the “Medical Home” that promotes strengthening and supporting the patient-physician relationship (American Academy of Family Physicians, 2008). This model entails a central resource with a competent team and active involvement by informed patients. It focuses on accessible, continuous, comprehensive, family- centered, coordinated, compassionate, and culturally effective care that promotes a continuous healing relationship. Integration of mental health care in this medical home opens the door to care that is more accessible to the patient, allows for whole person care (not carved out), is team focused and coordinated within the system, and improves overall quality and patient satisfaction.

TRAINING PROGRAMS FOR PRIMARY CARE HEALTH PSYCHOLOGY

In order for this type of integration to more fully develop, psychologists and PCPs need to be trained to work and function in this collaborative environment. It is unlikely that providers who have been schooled in their closed, non integrated systems will suddenly work as collaborators when they graduate from residency/fellowships and become practitioners. Since its conception in the 1970’s, family practice has appreciated and included behavioral science education into their residency curriculum (Garcia-Shelton & Vogel, 2002), welcoming psychologists and other mental health professions as a core part of their training faculty. More recently, the two physician residency accreditation bodies (ACGME and AOA), placed a strong emphasis on training in the Core Competencies. These competencies include, among other things, an emphasis on providing patient care that is compassionate, appropriate and effective and the demonstration of effective interpersonal and communication skills. These revised accreditation requirements have opened more opportunities for behavioral science faculty to be included in the training of physicians in internal medicine and pediatrics. Psychologists can and do contribute much to the training of physicians. But for psychologists to be considered effective educators and collaborators in a medical environment there is much they need to learn and appreciate about the medical culture.

Psychology training programs for learning this type of collaborative work are limited. Since 1987, Genesys Regional Medical Center (formerly St. Joseph Hospital and Flint Osteopathic Hospital) have offered a two-year postdoctoral fellowship in primary care health psychology. This program is part of the Consortium for Advanced Psychology Training (CAPT) and is affiliated with Michigan State University, Flint Area Medical Education. The CAPT fellowship program is accredited by the American Psychological Association.

During its evolution, the fellowship began with full integration within in a family practice residency and has expanded over the years to include internal medicine, obstetrics, and podiatry residency programs. The program was created to train psychologists to be consultants, collaborators, and teachers to PCPs in the broad area of the behavioral sciences. The overall goal is to bring the physician and psychology trainees together in an integrated and organized program to enable them to build relationships, increase collaboration, and learn from each other as colleagues.

CO-LOCATION & PHYSICAL ENVIRONMENT

The first place to start with developing collaborative working relationships is the physical environment. In our outpatient clinic settings, the health psychology fellows and faculty are integral to the residency teaching and clinical setting. Their offices are positioned in close proximity to the exam rooms and where the physician faculty precept cases. While more space might have been available to us on a separate floor or down the hall, we chose to be located as closely as possible to where physicians perform their daily tasks. If one colleague is in session with a client, we work to make sure that another has his/her door open and is available for the curbside consult. This reduces barriers to seeking consultative advice from the psychologist. In the inpatient environment, we work on the units of the hospital, make rounds with the medical teams, and are easily visible to residents. The goals are to be seen, considered, and utilized.

CONSULTATIVE/COLLABORATIVE CARE

Our model combines consultative and collaborative elements in various forms within the combined training program.

Didactic Teaching: The behavioral science curriculum for family medicine & internal medicine residency programs can be structured in various ways and still meet accreditation guidelines. While standard curriculum develops a working knowledge of common DSM-IV diagnoses and the PCP’s role in management of these conditions, our program places an increasing emphasis on patient-centered care and on the relationship building that is central to the medical home. The psychologist’s role is to help the physician appreciate the whole person approach to care and the value of a continuous healing relationship in effecting behavioral change. In addition, our didactic teaching examines the medical interview and helps the physicians be more effective at negotiating and setting an encounter agenda, developing focused interviewing skills, handling strong emotions, increasing collaboration with patients, and knowing when and how to transition to more traditional doctor-centered care.

Shadow/Video Precepting: One method of teaching and effecting change in the medical interview is for the psychologist to shadow or observe through video the encounter. Our teaching status in the residency programs makes this method of precepting a natural for both the physician and patient. When conducting this type of work the psychologist’s typical role is that of an observer who provides feedback to the physician outside the examination room, yet there are instances when our feedback is needed more immediately. Through this process, the psychology fellow learns more about medical culture, the pace of primary care, and the complexity of care with the primary care physician as their teacher. Likewise, the psychologist demonstrates and teaches new skills to the physician.

Hospital Consultation & Rounds: When the PCP transitions to the inpatient medical setting, the role of the psychologist may range from the traditional consultant (with formal referrals) to being part of the inpatient rounding team. The consultant role generally concerns patients with mental health disorders which are having an influence on the medical care and treatment of the patient. When rounding with the medical team, the psychologist’s emphasis is more on teaching and education of the team members, but in this situation too, the psychology fellow is also learning .

Individual Psychotherapy: When patients are referred to our outpatient psychology service our function is that of a consultant. These referrals include the full range of conditions and ages that are typical for a primary care setting. The patient’s diagnosis may be typical of general clinical practice (depression, anxiety, etc.) or may be more clinical health psychology in nature (coping with chronic or life changing illness, psychiatric conditions co-morbid with medical illness, pain management, adherence to medical advice, and lifestyle change). There is regular communication, face to face and written, about these shared patients with documentation typically in the same record. Both providers share an appreciation for what each brings to patient care.

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